Patient reported psychosocial functioning following successful ptosis surgery.

BACKGROUND: Ptosis may result in increased anxiety, appearance-related distress and social avoidance, and impacts visual function. Previous work demonstrates the benefits of ptosis surgery for health-related quality of life, but there is a paucity of research comparing such outcomes before and after surgery. The aim of this study was to determine potential patient benefits in health-related quality of life, social dysfunction and anxiety following successful ptosis surgery using validated measures. METHODS: Adult ptosis correction surgery patients completed validated measures of appearance-related social anxiety and avoidance, anxiety and depression, and fear of negative evaluation pre-surgery. Following successful surgery, these measures were repeated post-discharge in addition to another health-related quality of life measure. RESULTS: Of 61 patients recruited, follow-up measures were sent to 33 and completed by 23. Paired samples t-tests demonstrated positive significant changes in appearance-related social distress pre-op m = 30.94, post-op m = 23.67 (t(17) = 3.46, 95% CI 2.84-11.72, p = 0.003), anxiety pre-op m = 7.6, post-op m = 4.9 (t(19) = 4.27, 95% CI 1.38-4.02, p < 0.001) and fear of negative evaluation pre-op m = 34.79, post-op m = 31.26 (t(18) = 2.47, 95% CI 0.52-6.53, p = 0.024). There was no significant difference in depression scores pre-op m = 3.6; post-op m = 3.2 (t(19) = 0.672, 65% CL -0.85 to 1.65, p = 0.510). In total, 85% of patients reported positive benefit to well-being following surgery. CONCLUSION: Increasingly, evidence suggests ptosis surgery may benefit patient's well-being, appearance-related social anxiety and avoidance, as well as improving visual function. These psychosocial benefits should be considered alongside functional benefits in the provision of ptosis surgery.

Management of strabismus in thyroid eye disease.

Thyroid eye disease is an auto-immune condition characterised by an acute inflammatory phase followed by a fibrotic phase, which sometimes leads to restricted eye movements and diplopia. Medical treatment with systemic steroids with or without orbital radiotherapy and immunosuppression can control the inflammatory response. Strabismus surgery should be carried out only after the inflammation is no longer active and after any decompression surgery. Surgery comprises recession of tight muscles using adjustable sutures so as to maximise the area of binocular single vision. There is debate as to whether adjustable sutures should be used for the inferior rectus muscle. Patients should be encouraged to have realistic expectations, as binocular single vision may not be achievable in all directions of gaze and lid retraction may be made worse by surgery.

The psychological well-being and appearance concerns of patients presenting with ptosis.

PURPOSE: Ptosis affects both the function and appearance of the eyes and face, because of drooping of the eyelids. Previous research has focused on functional impairment; however, similar appearance altering eye conditions have been demonstrated to have major impacts on psychosocial functioning. METHODS: This study examines the psychological well-being and appearance concerns of patients presenting with ptosis recruited from Bristol Eye Hospital using validated questionnaires focusing on demographics and psychosocial factors before surgery. RESULTS: Patients reported higher levels of anxiety, depression, and appearance concern than population norms, with scores comparable to previous research examining the impact of other disfiguring eye conditions. Gender differences were observed, with almost half of females experiencing significant psychosocial issues related to appearance concern about their ptosis compared with 20% of males. Linear regressions revealed that the main predictor of poor adjustment to the appearance of ptosis was the level of concern an individual had regarding the negative perceptions of other people. These results implicate psychosocial factors and demographics as predictors of the development of appearance-related distress and compromised psychological well-being for patients with ptosis who are currently seeking surgery. CONCLUSIONS: This study provides clinicians with a greater understanding of the concerns of affected patients, and treatment motivations. The findings may also inform the development of patient reported outcome measures and support for patients, which targets the psychosocial impact of the condition.

Idiopathic isolated orbicularis weakness.

PURPOSE: Orbicularis weakness is commonly associated with seventh nerve palsy or neuromuscular and myopathic conditions such as myotonic dystrophy and myasethenia gravis. We report four cases of idiopathic isolated orbicularis weakness. METHODS: All four cases were female and the presenting symptoms of ocular irritation and epiphora had been present for over 7 years in three patients. All patients had lagophthalmos and three had ectropion. Three patients underwent full investigations which excluded known causes of orbicularis weakness. Two patients underwent oribularis oculi muscle biopsy and histological confirmation of orbicularis atrophy. RESULTS: All patients underwent surgery to specifically address the orbicularis weakness with satisfactory outcomes and alleviation of symptoms in all cases. Isolated orbicularis weakness may be a relatively common entity that is frequently overlooked. CONCLUSION: Early recognition of this condition may lead to better management and prevent patients undergoing unnecessary surgical procedures.

Appearance concerns in ophthalmic patients.

AIMS: This study aimed to determine the psychosocial and appearance-related concerns of a sample of ophthalmic patients by measuring a range of psychological, social, and demographic factors. METHODS: Standardized psychological measures including anxiety, depression, appearance-related distress, self-discrepancy, appearance salience and valence were administered to 98 participants attending ophthalmic outpatient clinics in either London, Bristol, Sheffield or Bradford. Differences between groups were explored using t-tests and ANOVA, relationships between all variables were investigated using Pearson's correlation coefficient. RESULTS: Although mean scores for psychological adjustment were within the normal range, some participants were experiencing considerable levels of generalized anxiety. Being older, male, and married or living with a partner was related to significantly better adjustment. Better adjustment was also related to a less visible area of concern, greater disguisability of the affected area, a more positive evaluation of their own appearance, less engagement in comparing themselves with others, greater feelings of being accepted by others, appearance being less important to their self-concept, and a smaller discrepancy between the persons ideal and actual appearance. CONCLUSIONS: A majority of ophthalmic patients adjust positively to the demands placed on them. By identifying the variables that are associated with successful adaptation, the specific psychological interventions and appropriate systems of support can be put in place to help those who are adversely affected.

The use of imiquimod in the treatment of periocular tumours.

PURPOSE: To review our experience with 5% topical Imiquimod in the treatment of periocular tumours. METHODS: Imiquimod, an imidazoquinoline, is an immune response modifier which has been shown to have potent anti-viral and anti-tumour activity. We present a retrospective case series of 5 patients who received topical Imiquimod for various eyelid tumours. Two patients were diagnosed with basal cell carcinoma of the eyelid, one patient with actinic keratosis, one with intraepidermal squamous cell carcinoma (Bowen's disease) and one patient had concomitant squamous cell carcinoma and intraepidermal squamous cell carcinoma. RESULTS: All 5 patients, with various eyelid neoplastic/pre-neoplastic pathology, responded well with clinical resolution, to treatment with topical Imiquimod. There were few adverse reactions to periocular use of 5% Imiquimod, with only 1 patient developing a chemical conjunctivitis which resolved on dose reduction. CONCLUSIONS: There is limited experience and published literature on the use of topical 5% Imiquimod in the treatment of periocular tumours. In our experience, it is a safe and effective treatment for periocular lesions, including actinic keratosis, intraepidermal squamous cell carcinoma, basal cell carcinoma and squamous cell carcinoma. To our knowledge, this is the first published description of the successful use of 5% Imiquimod in treating moderately differentiated squamous cell carcinoma of the eyelid.

Long-term efficacy of 2-0 Prolene brow suspensions for congenital ptosis.

AIMS: To highlight the long-lasting benefit of 2-0 Prolene brow suspension for congenital ptosis. METHODS: Retrospective case review of 38 paediatric cases at two centres in the United Kingdom. RESULTS: Six cases continue to have a successful functional and cosmetic result ranging from 6 to 10 years. CONCLUSIONS: Brow suspension with 2-0 Prolene can be long-lasting in some patients.

Psychological causes of non-compliance with electronically monitored occlusion therapy for amblyopia.

AIM: To analyse psychological causes for low compliance with occlusion therapy for amblyopia. METHOD: In a randomised trial, the effect of an educational programme on electronically measured compliance had been assessed. 149 families who participated in this trial completed a questionnaire based on the Protection Motivation Theory after 8 months of treatment. Families with compliance less than 20% of prescribed occlusion hours were interviewed to better understand their cause for non-compliance. RESULTS: Poor compliance was most strongly associated with a high degree of distress (p<0.001), followed by low perception of vulnerability (p = 0.014), increased stigma (p = 0.017) and logistical problems with treatment (p = 0.044). Of 44 families with electronically measured compliance less than 20%, 28 could be interviewed. The interviews confirmed that lack of knowledge, distress and logistical problems resulted in non-compliance. CONCLUSION: Poor parental knowledge, distress and difficulties implementing treatment seemed to be associated with non-compliance. For the same domains, the scores were more favourable for families who had received the educational programme than for those who had not.

Prevalence and risk factors for common vision problems in children: data from the ALSPAC study.

OBJECTIVE: To estimate the distribution and predictors of some common visual problems (strabismus, amblyopia, hypermetropia) within a population-based cohort of children at the age of 7 years. METHODS: Children participating in a birth cohort study were examined by orthoptists who carried out cover/uncover, alternate cover, visual acuity and non-cycloplegic refraction tests. Prospectively collected data on potential risk factors were available from the study. RESULTS: Data were available for 7825 seven-year-old children. 2.3% (95% CI 2.0% to 2.7%) had manifest strabismus, 3.6% (95% CI 3.3% to 4.1%) had past/present amblyopia, and 4.8% (95% CI 4.4% to 5.3%) were hypermetropic. Children from the lowest occupational social class background were 1.82 (95% CI 1.03% to 3.23%) times more likely to be hypermetropic than children from the highest social class. Amblyopia (p = 0.089) and convergent strabismus (p = 0.066) also tended to increase as social class decreased. CONCLUSIONS: Although strabismus has decreased in the UK, it and amblyopia remain common problems. Children from less advantaged backgrounds were more at risk of hypermetropia and to a lesser extent of amblyopia and convergent strabismus. Children's eye-care services may need to take account of this socio-economic gradient in prevalence to avoid inequity in access to care.

The psychosocial benefits of corrective surgery for adults with strabismus.

BACKGROUND: Few papers have addressed the psychological impact of strabismus in adults, with none comparing preoperative and postoperative data using standardised questionnaires relating surgical results and psychosocial outcomes. METHODS: 46 participants were seen at their 6 week preoperative and 3 month postoperative appointments. Standardised measures of anxiety and depression (Hospital Anxiety and Depression Scale), social anxiety (Derriford Appearance Scale), and quality of life (WHOQoLBref) were completed. RESULTS: Preoperatively, levels of depression were comparable to relevant population norms; however, levels of general anxiety were slightly raised and levels of social anxiety and social avoidance were significantly poorer than population norms. Surgery resulted in significant improvements in psychosocial adjustment with improvements on all study variables for the participant group as a whole. The non-diplopic group made more significant gains than the diplopic group. Approximately one third of study measures were significantly correlated with the objective measure of eye misalignment preoperatively dropping to only one variable postoperatively. Calculations involving the subjective measure of eye misalignment and study variables showed the opposite pattern with five variables achieving significance postoperatively. There were no clear sex or age effects apparent in the data. CONCLUSION: Strabismus surgery offers significant improvements to psychological and physical functioning.

Small margin excision of periocular basal cell carcinoma: 5 year results.

BACKGROUND: The traditional surgical management of nodular adnexal basal cell carcinomas (BCC) involves excision with 3-4 mm margins and primary repair. This may remove a significant area of healthy tissue, often necessitating a complicated reconstruction, without the confirmation that tumour excision is complete. METHODS: Nodular adnexal BCCs were excised with 2 mm margins, and the repair delayed for 2 days, providing time for histological confirmation of complete excision with formal paraffin sections. Any incompletely excised tumours underwent further resection, which was facilitated by the undisturbed wound edges. Repair was again delayed until further histological examination had confirmed complete excision. RESULTS: 5 year follow up data were available for 55 patients who had undergone small margin BCC excision with delayed repair. 10 patients required more than one excision to achieve clear margins. There were no recurrences. CONCLUSION: Small margin excision of nodular adnexal BCCs with delayed repair is a safe and efficient method. Delayed repair allows histological confirmation of complete excision and assists further resection if required. Preservation of healthy tissue is maximised allowing less radical reconstructive surgery without resorting to Mohs' labour intensive technique.

Amblyopia treatment outcomes after preschool screening v school entry screening: observational data from a prospective cohort study.

BACKGROUND/AIMS: Preschool screening for amblyopia has controversially been abandoned in some localities within the United Kingdom, on the basis that there is no clear evidence of benefit to support its continuation. Data collected within a birth cohort study were used to examine visual outcomes at 7(1/2) years in children who did or did not receive preschool vision screening. METHODS: Monocular logMAR visual acuity with and without a pinhole was assessed by orthoptists. Contemporary records were used to identify children who had been offered and/or received preschool screening. RESULTS: Of 6081 children, 24.9% had been offered preschool screening and 16.7% had attended. The prevalence of amblyopia was approximately 45% lower in the children who received preschool screening than in those who did not (1.1% v 2.0%, p = 0.05). The mean acuity in the worse seeing eyes after patching treatment was better for amblyopic children who received preschool screening than for those who did not; 0.14 v 0.20 logMAR (p <0.001). These effects did not persist in an intention to screen analysis. CONCLUSIONS: Preschool screening at 37 months was associated with an improved treatment outcome for individuals with amblyopia. However, the improvement was clinically small and disappeared when considering all children offered screening rather than only those who received it. Further research is needed into improving the effectiveness of vision screening for preschool children, while in the interim these data do not conflict with current recommendations for school entry screening by orthoptists.

Amblyopia treatment outcomes after screening before or at age 3 years: follow up from randomised trial.

OBJECTIVE: To assess the effectiveness of early treatment for amblyopia in children. DESIGN: Follow up of outcomes of treatment for amblyopia in a randomised controlled trial comparing intensive orthoptic screening at 8, 12, 18, 25, 31, and 37 months (intensive group) with orthoptic screening at 37 months only (control group). SETTING: Avon, southwest England. PARTICIPANTS: 3490 children who were part of a birth cohort study. MAIN OUTCOME MEASURES: Prevalence of amblyopia and visual acuity of the worse seeing eye at 7.5 years of age. RESULTS: Amblyopia at 7.5 years was less prevalent in the intensive group than in the control group (0.6% v 1.8%; P=0.02). Mean visual acuities in the worse seeing eye were better for children who had been treated for amblyopia in the intensive group than for similar children in the control group (0.15 v 0.26 LogMAR units; P<0.001). A higher proportion of the children who were treated for amblyopia had been seen in a hospital eye clinic before 3 years of age in the intensive group than in the control group (48% v 13%; P=0.0002). CONCLUSIONS: The intensive screening protocol was associated with better acuity in the amblyopic eye and a lower prevalence of amblyopia at 7.5 years of age, in comparison with screening at 37 months only. These data support the hypothesis that early treatment for amblyopia leads to a better outcome than later treatment and may act as a stimulus for research into feasible screening programmes.

Psychosocial and clinical determinants of compliance with occlusion therapy for amblyopic children.

AIMS: The objective of this study was to determine the extent that psychosocial and clinical variables influence parental compliance with occlusion therapy (eye patching) in children with amblyopia. METHODS: Children (n = 151) receiving occlusion therapy (eye patching) for the treatment of amblyopia were recruited from five orthoptic clinics in Bristol, UK. Parents completed a questionnaire based on Rogers' (1983) Protection Motivation Theory (PMT). The parents (n = 105) were also followed up 2 months later. Clinical data, including measures of visual acuity, were also recorded. Compliance with eye patching was assessed through self-report accounts of parents. Stepwise regression analyses were used to determine the factors predictive of compliance with eye patching. RESULTS: Self-reported compliance with eye patching at study entry revealed that only 54% of parents were achieving orthoptists' recommendations to patch their child. Perceived self-efficacy was positively associated with compliance and perceived prohibition of the child's activities were negatively associated with compliance. At follow-up, past behaviour accounted for the largest proportion of explained variance in patching behaviour followed by response efficacy, and prohibition of the child's activities. CONCLUSION: The present findings may serve to inform interventions aimed at enhancing current orthoptic practice to improve compliance in amblyopic children. The importance of 'self-efficacy' and past behaviour suggests that consultations with parents exhibiting higher levels of success with patching may elicit strategies that could be shared with parents experiencing difficulties with patching their children. In addition, it is possible that the perceived efficacy of the treatment could be enhanced if orthoptists emphasised evidence of improvements in visual acuity which may, in turn, foster the maintenance of eye patching.